Children in Syria are suffering from “toxic stress”, a severe form of psychological trauma that can cause life-long damage, according to a study that charts a rise in self-harm and suicide attempts among children as young as 12.

A report by Save the Children and its partner agencies in Syria paints a harrowing picture of the country’s children, 5.8 million of whom are in need of aid, after a war which reaches its sixth year next week.

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Authors of the study, the largest of its kind to be undertaken during the conflict, warned the nation’s mental health crisis had reached a tipping point, where “staggering levels” of trauma and distress among children could cause permanent and irreversible damage.

More than 70% of children interviewed experienced common symptoms of “toxic stress” or post-traumatic stress disorder, such as bedwetting, the study found. Loss of speech, aggression and substance abuse are also commonplace. About 48% of adults reported seeing children who have lost the ability to speak or who have developed speech impediments since the war began, according to the report, entitled Invisible Wounds (pdf).

Mohammed, an aid worker with Shafak, a Save the Children partner in Idlib, said children were in a state of constant anxiety: “We notice that they are always stressed and react to any unfamiliar noise – [such as] if a chair moves or the door bangs – because of their fear of the sound of airplanes and rockets. Children are increasingly isolated and don’t like to participate in our activities, and in the young children we’re seeing a lot of cases of involuntary urination.”

Firas*, the father of Saeed*, three, said: “My son wakes up afraid in the middle of the night. He wakes up screaming. A child was slaughtered in front of him, so he started to dream that someone is coming to slaughter him.”

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The majority of children interviewed showed signs of “severe emotional stress” and 78% of them felt grief and extreme sadness some of the time. The study focused on 458 children, adolescents and adults, and was undertaken between December 2016 and February 2017, in seven of Syria’s 14 governorates. It also revealed:

51% of adults interviewed said adolescents are turning to drugs to cope with stress

59% of adultssaid they knew children and adolescents who had been recruited into armed groups. Almost half knew of children working at checkpoints or barracks

One in four children is now at risk of developing a mental health disorder

Of the adults questioned, 60% cited the loss of education as one of the biggest impacts on their children’s daily lives. Since war began there have been more than 4,000 attacks on schools in Syria, according to Unicef.

The interviews, by Save the Children staff, partners and trained psychosocial practitioners, took place mainly in opposition-held areas, including Aleppo, Damascus, Dara’a, Hasakah, Homs and Idlib. The organisation is unable to operate in places held by the government or Isis, but the charity said that issues experienced by children in these areas are likely to be similar. Two-thirds of children had lost a loved one, had their home shelled or bombed or suffered war-related injuries.

In Madaya, which has been under siege since mid-2015, medical staff reported at least six children, the youngest a 12-year-old girl, and seven adults had attempted suicide in just two months.

All children’s focus groups and 84% of adults cited an “overwhelming feeling of being unsafe” as the single biggest cause of children’s high levels of stress.

Hala, a teacher in Madaya, said: “Children wish they were dead, and that they would go to heaven to be warm and eat and play. They wish they would be injured by a sniper, because if they got injured they would go to the hospital and leave the siege and eat whatever they want.”

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However, despite the high levels of need, in some regions of more than 1 million people, there is only one psychiatrist.

Alexandra Chen, a child protection and mental health specialist at Harvard University, said that toxic stress is the most dangerous form of stress response, when children experience strong or prolonged adversity without adequate adult support.

“This is likely to have a life-long and devastating impact on these children’s mental and physical health, disrupting the development of the brain and other organs and increasing the risk of heart disease, substance abuse, depression and other mental health disorders into adulthood,” said Chen.

She said that with an end to the violence and with the right support, children can recover.

“However, the child mental health crisis is reaching a tipping point in Syria just as family support structures and official services are collapsing.”

The report called for a ceasefire and for all parties to stop using explosive weapons in populated areas, schools and hospitals, as well as an end to siege tactics, and unrestricted humanitarian access to all areas. It also called on donors to commit to supporting children’s mental health in Syria.

Dr Marcia Brophy, a psychosocial adviser for the Middle East at Save the Children, said: “We risk condemning a generation of children to a lifetime of mental and physical health problems. We need to ensure that children who have already lost six years of their lives to war don’t have to lose their whole future as well.”

Some 13.5 million people inside Syria, including 5.8 million children, are in need of aid, Save the Children said. About 4.8 million people are trapped in besieged and hard-to-reach areas.

At least 250,000 people have died and 4.9 million, 2.3 million of them children, have fled the county, the majority to Turkey, Jordan, Lebanon and Iraq.